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Complaint Investigation

Landmark Medical Center

November 26, 2025 · Pomona, CA · 2030 N. Garey Ave.
Citations 2
CMS Rating 2/5
Beds 95
Provider ID 05A134
Healthcare Facility
Landmark Medical Center
Pomona, CA  ·  View full profile →
Inspection Summary

LANDMARK MEDICAL CENTER in POMONA, CA — inspection on November 26, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

During an interview on 10/22/2025 at 2:47 pm with Licensed Psychiatric Technician (LPT) 1, LPT 1 stated CNAs were supposed to do hourly visual checks on residents. LPT 1 stated it was important for CNAs to do hourly visual checks because incidents like suicide could happen. LPT 1 stated, We need to make sure they're (residents) alive and assess their behavior. LPT 1 stated incidents like resident-to-resident abuse could occur if staff were not checking on the residents hourly.

During an interview on 10/22/2025 at 2:56 pm with the Director of Nursing (DON), the DON stated the facility's standard was to check on residents every hour.

The DON stated whoever documented the monitoring must lay eyes (to see or look at the resident) on the resident or visualize the resident, To make sure they (residents) were okay.

The DON stated if CNAs or staff were not visualizing the residents every hour it posed a safety risk to the residents.

The DON stated if not visualized hourly residents could fall and be unable to ask for help, residents could go into another resident's room, and it could put the residents at risk for resident-to-resident abuse.

During a review of the facility's P&P titled, Policy for Hourly Monitoring of Residents, dated 5/2024, the P&P indicated it was the policy of the facility to provide an atmosphere that was safe and secure for all residents and staff.

The P&P indicated that each CNA was assigned a zone or area in the unit and would observe the location of resident assigned in their section, each hour, and document the location in the facility's electronic medical record (EHR).

The P&P indicated in documenting resident location in the EHR, staff were making an honest and accurate entry that they visually saw and identified the resident.

The P&P indicated the monitoring allowed the staff to account for each resident and ensured that each resident was free from distress.

Facility ID:

05A134

IDENTIFICATION NUMBER:

05A134

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Landmark Medical Center

2030 N.

Garey Ave.

Pomona, CA 91767

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 10/22/2025 at 2:56 pm with the Director of Nursing (DON), the DON stated the facility's standard was to check on residents every hour.

The DON stated whoever documented the monitoring must lay eyes (to see or look at the resident) on the resident or visualize the resident, To make sure they (residents) were okay.

The DON stated if CNAs or staff were not visualizing the residents every hour it posed a safety risk to the residents.

The DON stated if not visualized hourly residents could fall and be unable to ask for help, residents could go into another resident's room, and it could put the residents at risk for resident-to-resident abuse.

During a review of the facility's P&P titled, Policy for Hourly Monitoring of Residents, dated 5/2024, the P&P indicated it was the policy of the facility to provide an atmosphere that was safe and secure for all residents and staff.

The P&P indicated that each CNA was assigned a zone or area in the unit and would observe the location of resident assigned in their section, each hour, and document the location in the facility's electronic medical record (EHR).

The P&P indicated in documenting resident location in the EHR, staff were making an honest and accurate entry that they visually saw and identified the resident.

The P&P indicated the monitoring allowed the staff to account for each resident and ensured that each resident was free from distress.

During a review of the facility's P&P titled, [Facility] Policy on Documentation in Point Click Care (EHR), updated 1/2022, the P&P indicated all entries were to be made by the nurse who provided the nursing care or made the observation.

Facility ID:

05A134

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in POMONA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LANDMARK MEDICAL CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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